The threat of malpractice litigation in the United States is encouraging physicians again to assume responsibility for their patients. The fundamental ethical problem, however, is that this approach denies the patient's moral agency. In this essay, responsibility to patients, rather than for them, is discussed as an alternative to the emerging neo-paternalism. Responsibility to avoids the ethical problems of assuming responsibility for moral agents and could reduce the threat of litigation as well.

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As the bar continues its debate over suitable methods for controlling litigation costs, clients have become increasingly frustrated by the absence of truly effective solutions to the cost problem. Lawyers have tinkered endlessly with cost management techniques, but the bottom line-cost to the client-frequently remains unchanged. Many believe that the problem is endemic and that the court system will require major modification before meaningful reductions in litigation cost can be achieved. We may, however, be closer to real progress than many realize. The problem may simply be that wehave not yet applied "state of the art" concepts to the universe of dispute resolution in the courts.If we look at the principal methods by which we resolve disputes-settlement and adjudication-we see an obvious contrast. On the settlement side, we have made dramatic strides in our ability to settle cases efficiently and at minimal cost. Alternative dispute resolution (ADR) has proven that cases which otherwise might take years to litigate can be settled inexpensively in a period of months. ADR has demonstrated the fundamental benefits of having the parties themselves agree on a simplified set of procedures which permit the exploitation of the parties' powerful economic incentives to avoid unnecessary transaction costs in resolving the dispute.Unfortunately, not all cases settle and a vast number of disputes remain in the court system for final resolution. Except for isolated instances, opportunities for private initiative similar to ADR are not available in our court system. In the typical court proceeding, litigating parties have very little institutional control over "processing costs." Indeed, efficiency in the management of litigation is ordinarily treated as just one more issue to litigate.

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